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Annex II

F To be attached to the Application Form for the 6-month UNEP/UNESCO/BMU International Postgraduate Course on
Environmental Management for Developing and Emerging Countries at Technische Universität Dresden, FRG E

Medical Clearance Certificate

To be filled in and signed by a qualified medical practitioner

1. Name: ........................................................... Date of birth: ....………........................


Address: ...........................................................
...........................................................
........................................................... Country: ...........…….....................

2. Family History
What relatives or associates of the examinee have had tuberculosis?.......................….............….….........
What relatives or associates have had diabetes? ...........................................................................…….......
Have any relatives had nervous or mental disorders? .............................................................…..…............

3. Personal History
Has the examinee suffered from any of the following diseases? If so when?

Yes No When
Tuberculosis q q ................…..….......…......
Cardiac diseases q q ............................…….......
Gastrointestinal disabilities q q .......................…..……......
Arthritis q q ...........................……........
Genito-urinary or renal diseases q q .............................……......
Malaria q q ............................…….......
Diabetes q q ............................…….......
Acute or chronic respiratory diseases q q ...............................….…...
Has the examinee had typhoid fever? q q ....................…..…...…......
or anti-typhoid inoculation? (When?) q q .........................……..........
Polio q q .............................……......
Tetanus q q ...............................……....
or anti-tetanus inoculation? (When?) q q ...............................……....
Intestinal parasites q q ...........................……........
When was the examinee last successfully vaccinated against smallpox? .....................................
Any diseases or injury not noted above?
.........................................................................................................................................................
……………………………………………………………………………..…………………………....……..………..
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4. Physical Examination

(1) General development: q Good q Fair q Poor


Nutrition: q Thin q Average q Obese

Height: ............. Weight: ........……….... Best Weight: .......................…….…...

Any recent change in weight? ...............................…… When? ..................................….....


Temperature: .............°C
Comments:
..........................................................................................................................................…...............
.......................................................................................................................................……................
........................................................................................................................................…..................

(2) Skin: Any obvious disease? ..........................................................................................................

(3) Eyes: Lids ...................


Sight: right eye .................. left eye ...................

(4) Ears: Inspection .........................................................................................................................

Hearing: right ear .......................................... left ear .....................................…………......

(5) Glands ......................................................…...... Thyroid ………...........................................

(6) Condition of teeth …….........................................................................................................................

(7) Respiratory system:


Does physical examination reveal anything abnormal in the respiratory organs?
q Yes q No
If yes, explain fully:
................................................................................................…....................................................
.............................................................................................................................................................
..................................................................................................................................……....................

Examination of thorax (REPORT OF X-RAY, please do NOT include the film):


..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
.............................................................................................................................................................

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(8) Circulatory System:
(a) Heart: Any organic lesion?
..............................................................................................................................................................
..............................................................................................................................................................

(b) Rate and blood pressure - Standing ...............……..…...........


- Straight after hopping 25 times ......................…………...
- 2 minutes after the hopping ..............…..……...........

(9) Abdomen: Girth ................... Tenderness ................. Hernia .........………….......

(a) Palpable Liver …................................ Spleen................................…….…...........................

Kidneys ...…............................. Tumours .............................................….......……....

(b) Haemorrhoids .....…........................... Fistula................................................……................

(10) Nervous system: Indication of nervous or mental disabilities? ….........................................…...........

(11) Urine Analysis:

- Physical appearance ..................................................................................……..................

- Sp. Gr. .........................................................................................……..........

- Albumen ..........................................................................................….............

- Sugar .......................................................................................……….........

- Cells .......................................................................................……...…......

(12) Blood Analysis

- Haemoglobin .............................................................................................………………...

- Red cells per cm3 .............................................................................................…………..........

- Leucocytes per cm3 ............................................................................................…………...........

- Differential leucocyte count .......................................................................................……….............

(13) Does the examination reveal any facts not enumerated above affecting or likely to affect the health of the
examinee?
...........................................................................................................................................……………
.............................................................................................................................................…............
...............................................................................................................................................………...
..........................................................................................................................................…..............
……………………………………………………………………………………………...………………………….

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Concluding remarks about the health condition: ..................................................….................................
............................................................................................................................………………………..
.........................................................................................................................…................................
..........................................................................................................................…...............................
.........................................................................................................................…................................
........................................................................................................................….................................

Name of medical practitioner: ...............................................................................

Address: ........................................................................................…………....
...................................................................................………..……...
....................................................................................………………..
..................................................................................………..……....
Telephone : .................................................................…....…………
Fax: ..............................................................................………….……

.................................. ................................................….......
Date Signature

......................................................................
Seal

F Please, type or use block capitals! E

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